ddiction comes in
many forms: drugs,
alcohol, cigarettes,
and gambling have
been the types that
traditionally plagued society.
In recent years, the
proliferation of technology has
led to the rise of addiction to the
internet and computer gaming.
Even the promotion of a healthy
lifestyle has led some to become
hooked on exercise.
But do all addictions operate
by the same biological
mechanism? And is addiction an
individual’s choice or a disease of
the brain?
Scientists have been studying
addiction for years in order to
improve treatments for harmful
behaviour. They have found that
powerful memories, often of
highly pleasurable or intense
experiences, underlie addiction.
During such experiences the
brain releases a chemical called
dopamine that creates a reward
circuit in the brain, by logging
the intense experience as
pleasurable and an important
action to be repeated.
Dopamine release generally
occurs in a region called the
ventral tegmental area (VTA). In
response to this, epigenetic
changes happen in brain nerve
cells to form reward memories.
These chemical changes are a
mix of DNA methylation and
demethylation, which either
turns genes off or on.
Such a system allows changes
in how genes are expressed in
cells without altering our genetic
code, and forms a type of genetic
memory.
Addiction to all four major
classes of abused substances –
psychostimulants, opiates,
alcohol and nicotine – has been
linked to the same parts of the
brain associated with normal
reward processing.
Because of this, scientists
originally thought that drug
addiction took over normal
reward memory nerve pathways.
However, a more nuanced
picture is now emerging.
In normal reward processing,
the VTA signals to another region
of the brain called the nucleus
accumbens (NAC).
So when scientists blocked
methylation changes in both
these regions in rat brains, they
expected to block reward
memory formation.
Surprisingly, this happened
only when the VTA was blocked,
but not the NAC. This points to a
distinction in the chemical
regulation of reward circuits in
normal reward responses versus
addiction responses.
Dr Jeremy Day from the
University of Alabama at
Birmingham, who led the study,
says: “Although drug experiences
may co-opt normal reward

mechanisms to some extent, our
results suggest they also may
engage entirely separate
epigenetic mechanisms that
contribute only to addiction and
that may explain its strength.”
According to the Central
Registry of Drug Abuse, opiates –
such as heroin – have been the
most common drug abused in
Hong Kong; however, rates of
heroin abuse have been
dropping.
In its place, psychotropic
substances – which cross the
blood-brain barrier and act
primarily upon the central
nervous system – such as
cocaine, ketamine and
methamphetamine, have
become the drugs of choice.
Alcohol consumption peaked
in 2008 before decreasing in
recent years, according to a
survey by the Health
Department. Smoking has seen a
falling trend: cigarette smoking
prevalence dropped to a 30-year
low of 11.1 per cent in 2010.
While abusing drugs, alcohol
and nicotine typically kills you
gradually, another well-known
addiction that can kill quickly is
gambling, whether in casinos or
on the stock market.
In Hong Kong, a 2010 study
found that almost half of
gambling suicides in the city
were associated with large
gambling debts.
Now, a new form of
addiction is ensnaring youths
and adolescents with the
spread of the internet,
gaming technology and
smartphones.
Professor Daniel
Shek Tan-lei at
Polytechnic
University
conducted a study in
2011 that found 26.7 per
cent – just over a quarter –
of 3,500 students
interviewed were
considered addicted to the
internet.
Dr Alain Dagher, of McGill
University, believes that
abnormal interactions between
different decision-making
regions in the brain are the
underlying cause of addiction.
A specific region in the brain
called the dorsolateral prefrontal
cortex regulates feelings of
craving in response to cues. For

example, a smoker craves a
cigarette when they see or smell
someone else smoking. By
visualising how an addicted
person perceives a substance,
the imaging results can be used
to predict consumption.
Applying a technique called
transcranial magnetic
stimulation, a method that uses
magnets to induce weak electric
currents in the brain without any
form of surgery, the dorsolateral
prefrontal cortex can be
inactivated – and the craving
response can be altered.
Dagher says: “Policy debates
have often centred on whether
addictive behaviour is a choice or

Debates often
focus on
whether
addiction is a
choice or a
brain disease
DR ALAIN DAGHER, SCIENTIST

26.7%
of 3,500 Hong Kong students
interviewed in a 2011 study
were addicted to the
internet

a brain disease. This research
allows us to view addiction as a
pathology of choice. Dysfunction
in brain regions that assign value
to possible options may lead to
choosing harmful behaviour.”
Treatment of addiction
requires a multi-pronged
approach. These include the
gradual reduction of the abused
substance with the aim of total
abstinence, and counselling
services. Experts agree a key
aspect of addiction treatment is
social and family support.
Dr Bonnie Lee, associate
professor at the University of
Lethbridge in Canada, believes
that instead of treating addiction

in individuals, help should be
administered at the group level.
Lee has developed
Congruence Couple Therapy, a
model adopted by treatment
agencies in Canada, and which
Lee has taken to places around
the world, including Hong Kong.
“One could say relationship
breakdown is the root of
addiction in most cases, often
originating in childhood with
abuse, neglect and
abandonment,” she says.
“I like to see how family
members talk to each other. Like
a stage director, I reshape the
family interactions to promote
mutual understanding of fears
and hurts, as well as the sharing
of hopes and wishes.
“This collaborative spirit then
propels the therapy forward
because there is hope when
everyone works together with
realistic expectations.”
Lee believes congruence
therapy is particularly apt for
Asia. “Asian values prize the
family as the cornerstone for
individual and societal harmony
and well-being.
“The Taoist worldview of
interconnections resonates
with contemporary ‘systems
thinking’ in addressing the
individual as inseparable
from couple and
intergenerational
relationships.
“There is a lot in
congruence therapy that
would appeal to Asian
clinicians and clients.”
To treat addiction in
youths, Shek also believes
family support to be paramount.
Referring to youth development
programmes in Hong Kong, he
says: “Most focus on life skills
training, such as emotional
management. Family
intervention is also an effective
intervention direction.”
In Hong Kong, according to
Shek’s 2011 report, a youth
development programme aimed
at secondary school students
called Project PATHS made good
headway in reducing
adolescents’ delinquent
behaviour and substance use,
while increasing psychosocial
competencies and their ability to
control internet use.
As time passes, new types of
addiction may become
traditional, while newer ones
appear on the horizon.
Although addiction may be
multifaceted, scientists are
discovering common underlying
pathways in the brain that can
help shape treatment options.
By focusing rehabilitation
efforts on family and social
support, we are becoming
better equipped to battle
addiction, regardless of
its shape or form.
life@scmp.com

Downward spiral
Almost nine out of 10 people
in Hong Kongs have
deteriorating health,
according to a survey
commissioned by insurance
company AIA Group. In the
poll of 600 Hongkongers,
86 per cent said their health
was not as good as five years
ago. It’s the highest rate in the
region, where 10,245 adults
aged 18 to 65 years across 15
territories were surveyed.
Although 65 per cent of
Hongkongers indicated a
desire to lose weight, eight
in 10 said spending time
online prevented them from
getting enough exercise.
Among Hongkongers
under the age of 30, only
61 per cent exercised
regularly at an average of
2.3 hours per week.

No pregnant pauses
Women who exercise during
pregnancy could be setting
their child up for better heart
health in adulthood,
according to a new study in
the journal Experimental
Physiology. The American
Congress of Obstetricians
and Gynaecologists
recommends 30 minutes of
moderate intensity physical
activity on most or all days of
the week. In the study,
pregnant pigs exercised 20 to
45 minutes on a treadmill for
five days a week. The regimen
had a major effect on vascular
function in the swine’s adult
offspring, which the
researchers say may have
implications for future risk of
cardiovascular disease.

Correction
In the article on flat-head
syndrome titled “Out of
shape”, published on
October 9, 2013 in the South
China Morning Post, Dr
Hannah Tsang Yee-hoi, a
specialist in paediatrics, was
misquoted as saying that
syndromal disorders were
anxiety and depression. This
is incorrect. Examples of
syndromal disorders are
Apert syndrome and Down’s
syndrome. These are just two
examples of syndromes that
need to be ruled out by the
absence of other clinical
features before a child can be
diagnosed as having
positional plagiocephaly.

Diagnostic inﬂation: when quirks label us as crazy
................................................
David Wilson
life@scmp.com
Today it seems that almost
everyone is certifiably mad.
According to critics, amateur
and professional psychiatrists
are routinely guilty of
“diagnostic inflation”: turning
normal people into mental
patients with alphabet soup
diagnoses. In a new book,
America’s Obsessives, author
Joshua Kendall argues that
many great people have been
shaped by obsessive compulsive
personality disorder.
Other widely applied
questionable labels include
disruptive mood disregulation
disorder, which may mean
nothing more than children’s
temper tantrums, and social
anxiety disorder, which may be
shyness. Thanks to psychiatric
overreach, every quirk is judged
a mental disease, especially
if the US$300-billion-a-year
pharmaceutical sector has a pill
for it, the theory goes.
Meet florist Caren Ragan,
who says she has taken every
psychiatric test under the sun.
Much mental health diagnosis is
subjective, Ragan says.
Her mental health ordeal
stemmed from declaring
her intention to divorce her

ex-husband who, at the start of
a 10-year court battle, branded
her “paranoid-delusional”, she
says. Six times during her ordeal,
Ragan took one of the most
commonly used personality
tests in mental health: the
Minnesota Multiphasic
Personality Inventory.
Her answers were consistent,
she says, but the diagnosis
depended on the examiner. The
verdict varied from “normal” to
severe psychosis with paranoid
delusions. “Which was pretty
strange considering I worked,
raised a family and volunteered
at school and not one single
person ever noticed this severe
mental disorder,” she says.
Ragan adds that she was
prescribed several kinds of antidepressants for real, related
depression; all worked briefly
before she decided she had no
time to indulge in emotional
problems, which are a luxury of
rich countries, she says.
In the developed world, the
mental health industry is
booming. According to
psychologist Carole Stovall, an
expert in anxiety complaints
such as post-traumatic stress
disorder, mental health
prescription rates have
“skyrocketed”.
Stovall is appalled that
doctors prescribe psychotropic

We should not
reduce human
experience to
a checklist of
behaviour
PEGGY TILESTON, THERAPIST

drugs to children as young as six
months. “This is shameful.
Clearly, society is overprescribing,” she says. True,
she adds, careful medication
can help a patient. But
medication is often used “offlabel”, which can be
detrimental. All medication
has side effects, she says.
In fact, medication can
make you crazy. According to
the mental health watchdog
the Citizens Commission on
Human Rights, common and
well-documented side effects
of psychiatric drugs include
mania, hallucinations,
depersonalisation, suicidal
ideation, psychosis, heart attack,
stroke and sudden death.
The view that psychiatrists
recklessly medicate first and ask
questions later, pathologising

normality, is fuelled by an oftcited Canadian study. Children
born in December, close to the
cut-off date for entry into British
Columbian schools, were 39 per
cent more likely to be diagnosed
with attention deficit
hyperactivity disorder (ADHD)
than children born 11 months
earlier, the study found.
The University of British
Columbia researchers deduced
that younger students were
diagnosed with ADHD because
of their youth. The finding
suggested that the education
system is medicalising
immaturity.

According to the leading
critic of diagnostic inflation,
Allen Frances, we can cope
with plenty of pain because the
brain is naturally resilient and
self-healing – given time, people
get through rough patches.
Newly invented conditions
such as “major depressive
disorder”, which is grief in
Frances’ view, worsen a cruel
mental health industry paradox:
people desperately needing help
wilt unaided while the “worried
well” win the bulk of the
treatment, often to their

detriment, says the blurb for
Frances’ book, Saving Normal.
Defenders of labelling,
including the influential clinical
psychiatry professor Ronald
Pies, contest that it draws flak for
a suspect reason: society fears,
misjudges and reviles mental
illness, he claims.
According to City University
of Hong Kong social scientist
Daniel Wong, speaking in a 2011
BBC interview, mention of
mental illness makes people
think of danger and murderous
violence. So, some of the doubt
about diagnosis may stem
from prejudice.
Therapist Peggy Tileston
reckons that the psychiatric
profession merits some credit.
“I have witnessed much
good, including lives literally
saved, lives turned around for
the better, resulting from
conscientious, caring and
skilled psychiatrists accurately
diagnosing and prescribing
appropriate types and
levels of medication for
people with serious
mental health conditions,”
Tileston says.
Still, she has qualms.
While we no longer shut
people away in deplorable
asylums, we still have a long
road ahead.
“We still know so little about

the vastness of who we are as
human beings. It’s very quick,
convenient, clean and
comforting to organise,
categorise, and standardise
human experience,” she says.
“But we cannot and should not
reduce our messy and
multidimensional human
experience to a checklist of
symptoms and behaviour.
“The danger is that we miss
the unique person sitting right
there in front of us, or we see
only what’s wrong and different
from the norm,” she says.
Cue medication. A diagnosis
and a pill or product now
exists for almost any human
experience, according to
Tileston. “Have a human
condition that makes you or
me uncomfortable? There’s a pill
for that!” she says, adding that
over-diagnosis discourages
accepting what being fully
human means.
The reason for the alleged
clinical bias is a growing group
intolerance towards any
experience outside an
increasingly narrow range
judged “appropriate” or
“normal”, Tileston says.
She approvingly quotes a
patient who told her: “Normal is
a setting on a washing machine,
and not applicable to creative
individuals like me.”